“We want our patients to be able to go back to the lives they had before being critically ill.” This is the end goal of physiatrists in providing rehabilitative care and treatment, as emphasized by Dr. Celso Bate of The Medical City and the Victor R. Potenciano Medical Center, in the eleventh episode of UP’s STOP COVID DEATHS webinar series on July 3.
And that journey back is a long one.
In “Rehabilitation for Critical Care Survivors of COVID-19”, Bate clarified that because the disease is new, rehabilitative care and treatment protocols have yet to be established; but most helpful are existing strategies used in patients with prolonged confinement in the intensive care unit (ICU) and/or who are afflicted with acute respiratory distress syndrome (ARDS).
Critical COVID-19 patients are sedated and immobilized for a long period of time. Their muscles weaken. Their joints get stiff and painful to move. They get pressure injuries. And they even develop the risk of getting deep vein thrombosis and pulmonary embolism. They have difficulty swallowing because of intubation. Bate said that in ARDS, patients are usually intubated for three to five days, “but COVID-19 patients are intubated and extubated multiple times and they are intubated for weeks!”
“The things that are happening to COVID-19 patients and the care they require—we’ve never seen these things before: being on a ventilator for so long and so many procedures being done at the same time,” he revealed.
Rehabilitation of critically ill patients should start as soon as possible, even while they are in the ICU. “They grow two to three percent weaker with each day. . . . This is the price they have to pay to survive but we have to do something to reduce these effects.” According to Bate, all guided by the intensivists looking after the patient, the goal of early mobilization in the ICU serves to increase muscle strength and decrease reliance on mechanical ventilation.
Teaching critical care survivors how to go back to doing things that most people take for granted, like breathing normally, sitting, standing, eating, or even just being able to make simple hand and arm movements, is not as easy as it seems. “We usually give patients a year [to regain functional baselines],” he said, but stressed that patients must also be willing to rehabilitate themselves. “It is difficult, but it is the only way to regain strength.”
Apart from the toll critical illness takes on the body, it also wreaks havoc on the mind. Survivors experience anxiety, depression, and post-traumatic stress disorder. With COVID-19, the patients are mostly alone in their ICU rooms, which makes the situation more unbearable, although communication technology has been helping alleviate some of confinement’s negative psychosocial effects.
Patients also experience delirium as well as cognition issues. “Imagine you are heavily sedated, you have all these tubes attached to you and you can’t move nor speak. Then people in strange suits come in. You can’t see their faces, they talk funny, and they do all these things to you that you don’t understand. It’s traumatizing.” Bate recalled one patient who thought that having his temperature taken with an infrared thermometer was someone playing a dangerous game of Russian roulette with him and that each time the “gun” did not fire was a big relief because he was still alive.
While not all health care workers are psychology experts, “. . . we should always ask our patients about their concerns and give them explanations,” he said. Sometimes, the patients themselves ask to be referred to psychologists or psychiatrists, if their attending physicians have not already done so.
It takes a village, as the saying goes, and Bate agreed. “All of us in health care need to work together for the patient.”
Being free of the SARS-CoV-2 virus is just the first step toward recovery from COVID-19. And rehabilitation, which must begin in the ICU, continues on until critical care survivors have managed to return, as much as possible, to their functional and healthy selves.
To see Bate’s full presentation, go to this link.
The UP Webinar Series “STOP COVID DEATHS: Clinical Management Updates” is organized by the University of the Philippines in partnership with Philippine Health Insurance Corporation (PhilHealth) and the UP Manila NIH National Telehealth Center. The 13th installment of the webinar series, which will be held this Friday, July 17 at 12 n.n., will focus on ““Genetic Sequencing Research: Mutation of SARSCov2 (Implications for Clinical Management and Vaccine Development)”, with Dr. Cynthia P. Saloma, Executive Director of the UP Philippine Genome Center and professor of Molecular Biology and Biotechnology at UP Diliman as resource speaker.
Register here: bit.ly/StopCOVIDDeathsWebinar13.
(This was originally posted on the UP System website on July 14, 2020)